Alcohol Abusing Patients that experience Delirium Tremens during admission for hip fractures experience higher morbidity

Transcription

1 Alcohol Abusing Patients that experience Delirium Tremens during admission for hip fractures experience higher morbidity Cory Couch, MD Regis L. Renard, MD, MS, FACS, FAAOS University of Arkansas of for Medical Sciences, Department of Orthopaedic Surgery, Little Rock, Arkansas

2 Special Thanks Robert L. Garrison, MD James Kee, MD Jesse Wray, BS Eric Siegel, MS

3 Disclosures Orthofix, Inc. Stryker, Inc. Depuy-Synthes, Inc. Smith and Nephew, Inc. IGFS Committee Member

4 Background Alcohol abuse disorder is common 10% of women and 20% men in western societies Decrease life span Severe Reduction of alcohol intake leads to symptoms of withdrawal tremens -Delirium Tremens (DT)

5 Criteria for Alcohol Withdrawal Cessation or reduction of heavy alcohol consumption And at least two withdrawal symptoms

6 Criteria for Delirium Decreased attention/awareness Sensory Disturbance Cognitive Disturbance No other cognitive disorder

7 Delirium Tremens Meets criteria for Alcohol Withdrawal and Delirium Untreated DT with the current benzodiazepine treatment regimens have reported mortality rates of 1-4%

8 Hip Fractures Hip fracture incidence is % Usually require surgery and hospitalization Poor outcomes in hip fracture patients who abuse alcohol

9 Objective Effects of DT on acute hip fractures patients Incidence of DT in at risk patients with hip fractures Characterisitics of DT vs. Alcohol Abusing patients with hip fractures Identify rates of morbidity, mortality, and increased health care utilization

10 Objective Evaluate effect of DT prophylaxis on alcohol abusers suffering hip fractures

11 Hypothesis DT in hip fracture patients will have an increase of inpatient morbidity, mortality, and health care resource utilization

12 Inclusion Criteria ICD-9 Diagnosis codes for Subtrochanteric, intertrochanteric, neck or head femur fractures , , , , , , , , and ICD-9 Diagnosis codes for Alcohol abuse and/or Delirium Tremens diagnosis 291.x, 303.0x, 305.0, , , , 980.0, 980.0, 980.1, 980.2, 980.3, 980.8, 980.9, E860, E860.0, E860.1, E860.2, E860.3, E860.4, E860.8, E860.9, V11.3, V70.4, V79.1

13 Exclusion Criteria Incomplete records or imaging Patients younger than 18 years of age Periprosthetic fractures Non-operative greater trochanteric fractures

14 Methods Institutional review board approval Retrospective chart review April 2006-August 2015

15 Methods Occurrence of DT in alcoholic hip fracture patients Characterisitics of DT vs. Alcohol Abusing patients with hip fractures Age, gender, Charleson Comorbidity Index, Injury patterns, Surgical treatment Evaluated morbidity, mortality, length of stay, and ICU utilization

16 Statistical Analysis Fisher s exact tests Wilcoxon rank-sum test Kaplan-Meier curves

17 Results 86 patients identified 45 patients met inclusion criteria

18 Demographics Age (mean) Sex Charleson Co- Morbidity Index No DT 53 69% Male 2.2 DT % Male 3.1

19 Fracture Type Fracture DT No-DT Femoral Head 0 % 6.1% Femoral Neck 14.3% 45.5% Intertrochanteric 71.4% 33.3% Subtrochanteric 14.3% 15.1%

20 Surgery Type Surgery DT No-DT ORIF 0% 15.2% Intramedullary Nail 85.7% 48.5% Sliding Hip Screw 0% 3% Hemiarthroplasty 14.3% 15.2% Total Hip Arthroplasty 0% 12.1% Closed Treatment 0% 6%

21 Results 16% experienced DT LOS significantly longer in the DT group (p=0.0013) DT No-DT 0 LOS

22 Results ICU DT group more likely to require an ICU stay (p=0.0018) 11% DT No DT 71%

23 Results ICU LOS was significantly longer (p=0.0052) Inpatient complications significantly higher (p=0.0035) ICU LOS DT No-DT

24 Results DT patients more frequently received benzodiazepine treatment Duration of prophylaxis not significantly different Number of prophylactic regimens not significantly different

25 Results 3 Significant delay to surgical intervention in DT patients (p=0.04) DT No DT 0 Surgical Delay

26 Discussion Patient characteristics DT trending to be older male patients with higher CCI from low energy mechanisms The non-dt ETOH abusing patients included a higher proportion of trauma patients therefore a greater range of treatments and injury patterns. Also likely reason for younger age.

27 Discussion DT group suffered significantly more inpatient morbidity Sepsis, Pneumoniae, Aspiration DT group experienced a significant delay on average of almost 2 more days until having surgical treatment

28 Discussion DT group Significant increase in LOS: 20 vs 6 days Significant increase in ICU Days : 8 vs 1 days These increases are likely due to the increased morbidity experienced by these patients

29 Discussion Alcohol supplementation Prophylactic regimens utilized

30 Discussion Potential biomarkers for DT screening: Phosphatidylethanol May be a marker for chronic alcohol intake Carbohydrate-deficient transferrin (CDT) Blood ethanol

31 Discussion Weakness Retrospective chart review Diagnosis entry errors? Limited Number of Patients

32 Conclusion DT may occur in 16% of at risk alcohol abusing patients that suffer a hip fracture Patients with hip fractures complicated by DT have significant increases in inpatient morbidities DT hip fracture patients have significant increases in resource utilization Aggressive use of DT prophylaxis in at risk hip fracture patients

33 Conclusion Further studies? National hospital database review Review non-alcohol abusing hip fracture patient characteristics at our institution

34 References Johnston et al.hip fractures and chronic alcohol excess: a series of 7,023 cases. Hip Int Dec 5;24(6): Pasoto et al. Osteoporotic hip fractures in non-elderly patients: relevance of associated co-morbidities. Rheumatol Int Oct;32(10): Stearns et al. Displaced intracapuslar hip fractures in the working age alcohol-abusing patient. Scott Med J Feb;54(1): Berg et al. Association between alcohol consumption and both osteoporotic fractureand bone density. Am J Med May;121(5): Mukamal KJ, Robbins JA, Cauley JA, Kern LM, Siscovick DS. Alcohol consumption, bone density, and hip fracture among older adults: the cardiovascular health study. Osteoporosis Int May;18(5): Felson DT, Kiel DP, Anderson JJ, Kannel WB. Alcohol consumtion and hip fractures: the Framingham Study. Am J Epidemiol Nov;128(5): Zhang X, Yu Z, Yu M, Qu X. Alcohol consumption and hip fracture risk. Osteoporos Int Feb;26(2):

35 Thank You